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Bond Eye Associates - LASIK Quiz
Are you a candidate for LASIK? Take our quiz & find out!
11
Questions
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HIPAA
Compliance
1
What is your current age?
*
This field is required.
Under 18
18 - 39
40 - 59
60+
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2
Are you in good general health?
*
This field is required.
YES
NO
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3
Do you currently wear...
*
This field is required.
Glasses
Contacts
Glasses & Contacts
Nothing
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4
Without corrective lenses, do you have...
*
This field is required.
Trouble seeing far away
Trouble seeing up close or with reading
Overall blurry vision both distance and near
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5
Are you being treated for severe dry eyes?
*
This field is required.
YES
NO
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6
Have you ever had eye surgery?
*
This field is required.
YES
NO
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7
Have you ever been diagnosed with astigmatism?
*
This field is required.
Yes
No
I don't know
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8
Have you ever been diagnosed with cataracts?
*
This field is required.
YES
NO
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9
What is your name?
*
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First Name
Last Name
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10
What is your phone number?
*
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Area Code
Phone Number
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11
What is your email address?
*
This field is required.
By including your email address, you are providing consent for Bond Eye Associates to send you marketing emails in the future.
example@example.com
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